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Okay. Good morning, everyone. Um, thanks very much for joining. So just give a brief introduction. My name? Zuman McArdle. I'm a pharmacist. I've been working for a number of years in in different areas, and, uh, one area that I thought would be of interest is to look at, uh, some antibiotics, Obviously very difficult to to cover, um, everything pertaining to antibiotics in an hour. But I've chosen the pharmacology of macrolides aminoglycoside, tetracycline, chloramphenicol, and we will aim to look at those from a prescribing point of view. Um, from from physicians or medics. And then from the point of view of a pharmacist and And what advice and help that, uh, pharmacists I would do when working alongside medics when prescribing the antibiotics mentioned. So the topics that we will cover will be bacteria static versus bactericidal, having macrolides aminoglycoside, tetracyclines and chloramphenicol and then questions at the end of force. So bacteria static versus bactericidal. Essentially, um, there are the two in very simple terms. Drivers of of antibiotics and and how we and why we use antibiotics, bacteriostatic agents, our agents that prevent the growth of bacteria so they keep bacteria in the stationary growth phase. Where bacteria Seidel is an agent that kills bacteria. So very simply, if you can see here that we have the bacteria, uh, the first little images if new antibiotics are present, bacteria multiply and and commercial infections where bacteria static antibiotics will prevent bacteria multiplying and US help kill off the infection and bacteria. Static antibiotics kill the bacteria and help to kill off infections. So macrolides. The macrolides, as you may know, have a similar antibacterial spectrum to penicillin, however not wholly identical. Therefore, they are an example of alternative treatment for patients that are penicillin. Allergic Uh, a rhythm is is very commonly used as a first line for select infections in penicillin. Allergic Patient's. Uh, other examples of macrolides include clindamycin and azithromycin. They are active against many penicillin resistant staphylococcus I. However, some of these are not resistant to the macrolides, and I thought it would be interesting to just put this point in in yellow, um, with respect to antimicrobial stewardship, which is the systematic effort to educate and persuade prescribers of antimicrobials to follow evidence based prescribing to help stem antimicrobial overuse and thus antimicrobial resistance. So this is something that's a very hot topic. Um, and I have a brief slide on this at the end. It's just to consider, um, the anti Mao antimicrobial use and to consider antimicrobial stewardship. So the first macrolide discovered, um, was a ritual mason, uh, this was first used in 1952. Um, and indications include, but are not limited to campylobacter enteritis. Uh, respiratory infections and skin infections. Uh, the usual dose that we see for retro medicine, uh, in a healthy adult would normally be in the range of 250 to 500 mg four times a day for either seven days or 14 days. So what is the mechanism of action or the antimicrobial mechanism? Um, well, it appears to be the same for for all macrolides and how do they work? So obviously trying to keep this is sort of high level and as simple as possible to get through as many. But But we'll look at exactly what they do and and how they bring about their Axion. So at the very basis, um, macro lodge interview with protein synthesis. Uh, and this is achieved by reversibly binding to the fiber west sub unit. of the rib zoom through binding at the donor site, they prevent the translocation necessary to keep the peptide chain growing. Uh, this in effect, in essence, is confined to rapidly dividing bacteria and Michael plasmas. And whilst it's regarded as bacteria static, it also or macrolides also demonstrates bacteria seidel activity. So the fiber west is the largest subunit of 70 s. Ribosome of pro carry out, uh, bacteria being one of those. And it is the side of inhibition for antibiotics such as macrolides as mentioned chloramphenicol clindamycin. And it includes the five s ribosome, all RNA and the 23 s ribosome o r n a. So obviously we have a number of macrolides. Um but I thought, you know, for each of the antibiotics, we look at one within the class. So for this, we will look at the Reformation. Um, it is mainly used, uh, in susceptible patient's, uh, susceptible infections and patient's with penicillin. Hypersensitivity. So, as mentioned, has a very similar, um, make up almost but but not identical to to penicillin. So So those patients that are penicillin allergic, we tend to use macrolides, uh, to treat. So what are some of the infections where they may include respiratory tract infections, uh, including legionella skin and oral infections. And also compile a factor enteritis uh, the the the the MHR a medic, Medicines and Health Regulatory agency. Um, they issued advice in December 2020 regarding, um, erythromycin. Uh, and there is an increased risk of cardiotoxicity, uh, when using macrolides. So as such, we should avoid using patient's with history of QT, interval prolongation, or ventricular arrhythmia, or electrolyte disturbances. And that is due to the cardiotoxic risk. Um, there is a risk of Prasad is points with the use of macrolide. So again, patient's with the history of QT, interval prolongation, ventricular arrhythmia or electrolyte disturbances. We should avoid the use of macrolides in these patient's. And I think this is where physicians and and and medics very much come together when, when looking at the prescribing of medications when looking at prescribing of medication for acute illnesses such as infections. So you do really want to get the whole picture of the health of the patient, Uh, and very much, you know, it's a it's a cross functional decision. It's a multidisciplinary team decision when you are prescribing antibiotics. You please use the farms. That's another healthcare professionals that may help, um, with the use of macrolides and pregnancy. It's uses only to be used if the potential benefit outweighs the risk. Um, and I think it's always important to ensure that patient's are involved in decisions regarding their care. Um, the pharmacist of physicians would usually explain our council patient's on these risks, um, and information pertaining to to those counseling sessions or discussions with the patient's, especially if they pertain to the the treatment options of the patient should always be documented in the patient's notes. Um, hepatic impairment again cause she needed and renal impairment in moderate to severe renal impairment. We should consider dose reduction because there is an increased risk of phototoxicity uh, renally impaired patient's when using macrolides. So what? What are some of the side effects that we might see the common side effects with macrolides? Uh so So very commonly, we see gastrointestinal, uh, effects gastrointestinal symptoms. Uh, one of the big things to look out for is antibiotic associated colitis, uh, symptoms below care. Uh, it's treatment must be stopped. Uh, such as watery diarrhea, abdominal cramps, abdominal tenderness, abdominal pain, a fever, pus or mucus in the stools? Uh, nausea and dehydration. So if there is a risk or it looks like a patient is developing antibiotic associated colitis, it's very important to stop treatment. Um, if the patient does present with with any symptoms um, such as nausea or dehydration or or and watery diarrhea, it's important that you do treat the symptoms. Um, we can prescribe things such as antiemetics or antipyretics. Um, oral rehydration therapy, if needed. These are some of the ways in which we can counteract some of those, uh, side effects that may crop up when treating a patient with, uh, macrolides. Another important thing to look out for is a Colles static jaundice. Um, cholestatic. Jaundice occurs most commonly with the rhythm eyes and estimate um, jaundice usually appears after 10 days of use, um, primarily in adults. Um, it can occur earlier, earlier if the drug has been given previously. So that is something to be mindful of. Uh, and as we discussed earlier with the Mph, are a advice on risk of cardiotoxicity. Another side effect is the risk of QTP interval prolongation. So that's something else that we need to, uh, look out for, uh So next we can look at the immuno glycosides. And briefly, um uh, they are among the most widely used antibacterial drugs. Certainly we're seeing more and more of these used in practice. Uh, they were first introduced in the 19 forties. Uh, and the first use of aminoglycoside came in 1940 for, um, with the administration of step to mason to a patient for tuberculosis. Other examples of aminoglycoside include gentamicin um, occasion. Um, tobramycin. So what are the aminoglycoside used to treat? Uh, well, they used to treat a variety of bacterial infections. Uh, they are most effective against aerobic gram negative infections, including pseudomonas aeruginosa. Uh, they are ineffective against strep to Kokkai and anaerobic bacteria. So again, when looking at something like the use of amino glycosides and you're concerned about what the patient may be suffering from, um, oftentimes we can take swab samples of of areas or sputum samples, um, to ascertain what the bacterial infection actually is. And then we can use targeted therapy, targeted treatment, um, and using these important methods of ascertaining what a patient may be suffering with, or um uh, you know what the infection is is a key example of the use of antimicrobial stewardship, which is which is what we talked upon, uh, briefly earlier. So many black sides. How do they work with their bacteria side of antibiotics so they kill off bacteria. Uh, so you have it there, bacterial killing it It is concentration dependent, which we will look at, uh, in a little bit. So what is the mechanism of Axion? So the mechanism of action aminoglycoside cross the order bacterial membrane via pouring channels. Uh, and then they bind to the 30 s. Ribosome. Oh, subunit, uh, which inhibits protein synthesis, uh, interfering with initiation complex. So essentially, they induce a misreading of genetic code on the, uh, bacteria mrna A. Uh, this also causes the break up of polys OEMs into monosome, which is important because the polys OEMs are needed in the translation or formation of multiple copies of a polypeptide. So the mini glycosides some important and significant side effects that we must be mindful of. Uh, they cause nausea and vomiting. So how do we counteract that? Um, well, we could consider co prescribing, uh, antiemetics to counter act as side effect. Um, so that might be something such as cyclizine or metoclopramide. Um, so something to consider a co prescribing. Essentially, we often see, uh, anti emetics prescribed as a p r N medication and then in a patient's drug chart. So when required only. So you could consider prescribing co prescribing an antiemetics to counteract the side effect of nausea and vomiting. Um, net for toxicity, uh, is a big one. Um, and there are factors that increase the risk of Neffa toxicity in a patient that is prescribed an aminoglycoside. Uh, and and some of those risk factors include, uh, old age, Uh, renal or hepatic impairment? Um, pregnancy and hypothyroidism. And another very important thing to be mindful of when prescribing Amina glycosides is the risk of fetal toxicity. So there there's a potential severity of auditory and vestibular deficits. Depends on the particular I mean, a glycoside used, um, so neomycin is considered the most highly toxic. I mean, a glycoside with the greatest risk of phototoxicity, uh, followed by chantome izing economizing on tobramycin while AM occasion and natamycin are considered the least toxic. So looking at the, um, any glycosides, uh, we will use the example of gentamicin. Uh, it's a very commonly used to, obviously in secondary and tertiary care in the N. H s in the UK and with gentamicin, the effectiveness is concentration dependent, so this is very important to consider. So as such doses are adjusted according to serum gentamicin concentration, so often we see, um, regular blood is being taken from patient that are prescribed gentamicin to ensure that they are within the therapeutic window. And it's very important to consider the therapeutic window for the amino glycosides because, as we discussed in the previous slide, there's a risk of net for toxicity. There's a risk of phototoxicity, so it's it's It's something that we do need to consider, uh, and when prescribing Amina glycosides that their their mechanism of action is also serum concentration dependent. So it's a fine balance between treating the patient with the antibiotics but also protecting the patient against any potential adverse risk. So as the effectiveness of concentration dependent and doses are adjusted according to same gentamicin concentration, it's very important when prescribing gentamicin to ensure um, blood samples are are being requested or booked, and to also ensure that when handing patient's over. So from one shift to another shift that that any of the physicians that may come across the patient's are are well aware that the patient is being prescribed in a gentamicin or aminoglycoside well aware that, uh, serum uh, levels are required, Um, for each of those patients'. So it's just something to be mindful of when prescribing an aminoglycoside. So as we mentioned there, uh, there's a big risk of phototoxicity and something that we always need to be mindful of. And and with this, there's an increased risk of deafness. So we need to be quite cautious. We want to consider the familial history of of Patient's. We want to ascertain if any patient's have have had adverse effects or if there's been any examples of phototoxicity in in the family. Uh, and again it is looking at the wider picture when, when using antibiotics, it's essentially the. What I wanted to discuss during this lecture is that there are many things to consider. Yes, we need to look at the pharmacology. Yes, we need to ensure that the medications were prescribing or appropriate. We need to ensure that they're safe for the patient's, but we also need to consider adverse effects. We also need to consider risk versus benefit. Um, so again, it's looking at the whole picture. Is using the multidisciplinary team, um, to ensure that we're using the correct antibiotics and that again we're looking and discussing with our patient's so any patient's that will be prescribed aminoglycoside we do consider deal to toxicity, and we do need to inform the patient of that. We do need to do the due diligence and ensure that the patient's are aware of any risk versus benefit. So as mentioned before as well, um, dose adjustment is needed in renal or hepatic and permit. So that's something we need to be mindful of. And again unsurprisingly, um, we need to consider pregnancy with the medical. Besides, because, of course, this is linked into the auto toxicity toxicity risk. Um, in pregnancy, there is a risk of auditory, um, or the stimular nerve damage to an infant and on born infant if used in the second or third trimester. So we need to avoid this unless essential. So again, if it was absolutely essential that a pregnant lady needed an aminoglycoside, we would absolutely have to inform the patient of any potential risk for damage from a little toxic perspective to the infant and ensure that the mother is kept well, apprised of any potential risk for any side effects. And this is where I, I think again to mention that physician and pharmacist relationship, pharmacist or expert to counseling, patient's and informing patient's of risk and, uh, side effects and symptoms to look out for word using a medication. So again, um, it might be useful to lean on on a pharmacist to counsel a patient and actually explain the risk to the patient, Of course. Um, with the physicians support so we can look now at, uh, at for seconds and tetracyclines Uh, the antibiotics. Uh, the class was first discovered in 1948 and there's a number of tetracycline that we do see. Um, in practice, uh, for a variety of, uh, indications and some of those, uh, tetracyclines that we do see, uh, include Oxy tattoo, cycling, doctor, cycling, tattoo, cycling, and again just to highlight the efficacy is winning due to development of bacterial resistance. So again, it brings us back to that very important point that we need to consider that we're prescribing appropriately. We need to consider that we are being guardians for for antibiotics. Um, and that's something that we see across the UK and in the N H s is to be an antibiotic guardian, and again, that is just to flag up the risk of antimicrobial resistance. So it seems to be a relatively common theme with some of the antibiotics that were looking at. And it's no different for Texas cyclones that there is a reduction in the ethics be due to development of bacterial resistence is just something again to be mindful of. Um, that said, however, tetracyclines is a class are still used for a wide range of bacterial infections. The tetracyclines have a broad spectrum of anti of activity. Um uh, broad spectrum antibiotics widely useful. Um, and that's because they're active against a number of of gram positive and gram negative infections. So what is the mechanism of action of set of cycling's so they essentially have protein synthesis inhibitors, um, tetracycline to prevent the binding of amino actual t r N a. To the mRNA ribs, um complex, uh, tetracycline. To prevent both the formation and elongation of the polypeptides chain, uh, processed, inhibited 230 s, rival sumo sub unit bacteriostatic. So they prevent further bacterial growth rather than actively killing bacteria. And what are some of the indications that we commonly see certainly for the use of Tetris cycling's in in the the UK? Well, the indications that that we see at the moment include moderate to severe acne and rosacea. Uh, we see them in Not many, but but we do see them. Uh, well, with the moderate severe acne and rosacea, we tend to see, uh, that prescribed in primary care. Okay, we see GPS prescribe it, um, in primary care for severe acne and rosacea, whereas with, um, the l r T i s the lower respiratory tract infections such as COPD exacerbations and pneumonia both atypical and typical. We we actually see quite commonly, uh, doxycycline, used in secondary and tertiary care. Um, this time of year, winter respiratory tract infections tend to rise. Pneumonia tend to rise. Patient's suffering from COPD tend to have greater number of exacerbations in the winter. Uh, and we tend to see doctor cycling used, um, in secondary care quite often in in in that cohort of demographic of patient's that would suffer with COPD and pneumonia. We can also see doxycycline news and primary care for the for these indications. Um, other indications include committee Elin flexion or pelvic inflammatory disease, uh, syphilis and malaria prophylaxis. So with the type of cycling's, as mentioned, resistance is common and continues to develop. So we need to be mindful of prescribing these medications, ensure we're using them for the right indication, ensure we're using them for the right time and ensure that we complete the course of treatment. Uh, there are three main means of bacterial resistance. The three main ways in which bacterial resistence is rising with Ted for cycling's, and those three main means are formation of the efflux pump. So with the efflux pump, bacteria can in essence, pump out Tet recycling from the sale of the bacteria, we have n dramatic inactivation, which is a much rarer cause of resistance. And then we have ribosome oh protection and with ribs for more protection. Uh, the bacteria can prevent tetracyclines from binding to the bacterial Viber semmel subunit. So three million remains of bacterial resistance and and in some essences, that's quite concerning, uh, you know how well bacteria can actually begin to develop, grow and and and essentially evade. Um, so we've been with with with tetracyclines, uh, so tetracyclines. Um what what are some of the prescribing points you need to consider? So again, from a pharmacist standpoint, we would look at common side effects and and we would need to ensure the patient's who made aware of these and that any, uh, risk of common side effects of flags. So what are some of the common side effects? So some of the common side effects that we see are phototoxicity uh, we can sometimes see GI side effects. Uh, such as nauseous, nauseous feelings or boil Upset. Uh, diarrhea, Uh, we can see dental hyperplasia, uh, tooth discoloration. And also, we can see a soft agio irritation so very important to make sure that we control patient's in some of the risk of side effects. Actually, the patient's are involved in their care, and, uh, they're making an educated decision on treatment that they may want two other things to consider, uh, with tetracyclines. So if you consider just to look back the dental hyperplasia and tooth discoloration, it might give you an in cleaners to what we should avoid with this and one of the things we should avoid. Or we should avoid the use of tetracyclines and pregnancy. Um, due to the binding to the teeth and bones during fetal development infancy, um, and and early childhood. We should also avoid in the use of Children under the age of 12 again due to dental hyperplasia, uh, and and and this can have an impact on the development, uh, of the young child who's developing and growing. We should also consider, um, with tetracyclines, um, that we should avoid taking these with multi violent ions. So more often these days, we're beginning to see patient's, um, and most people taking supplements. Um, they may take a very sort of common one we see now is zinc. Um, we also see calcium supplements being taken. Certainly an elderly patient, you might have osteoporosis. Uh, they may be taking calcium tablets two tablets twice a day. We can often see, um, also aluminium and magnesium. So the reason why we need to be mindful of, uh, supplements or supplementation, um, when taking taxis cycling's is that they can cause collision. So essentially, uh, multibillion die on such a zinc. Calcium, aluminium, magnesium can cause collision. They combine the taxis cycling and can reduce the therapeutic effect of the drug itself. So we need to be mindful when prescribing. Certainly, uh, council Patient's, um, if patient's or inpatient and on their medication charts. They're taking calcium supplements or multivitamin supplements that we should leave two hours before, um, or after with multivitamins. So if you were taking or prescribing a tetracycline twice a day, um, at eight in the morning and eight at night, we would ensure that the patient was not taking any multivitamin Dion's multivitamins, calcium supplements or otherwise, either two hours before, um, or two hours after, uh, the tattoo cycling. So just something to be mindful of. Uh, Tetreault Cycling's may cause theater Tosis uh, and liver toxicity. So we need to monitor. We need to monitor this, uh, inpatient on long term use. Uh, so as mentioned in primary care, um, we might see patient's being treated with severe acne with a long term tech recycling. So you would want to monitor, uh, their liver function test, um, over the course of treatment just to ensure that uh, there is no liver toxicity. There is no, uh, liver damage or stay ketosis. Um, one of the side effects that we mentioned also, uh, I was looking at a soft jail. Um, irritation. So one way to counter act against that would be to ensure that patient's are sitting upright when they take their medication, uh, to take this with a full glass of water. Um, because, you know, very simple, but it will help prevent that esophageal irritation and give a better experience for the patient that is being treated. And tetracyclines, as we mentioned, can cause, um, gastrointestinal symptoms. They may cause nausea. They may cause vomiting or Mrs. So one way to help to suppress that side effect of tetracycline, um, is to counsel the patient and ask them to take the tetracycline with food. Because this can help to reduce those GI symptoms of nausea and vomiting as mentioned. Okay, so now the last antibiotic that we will look at, uh will be chloramphenicol, and the chloramphenicol was first discovered in 1945. Um, it's commonly used in some indication that it can be used for and not so commonly used in others and we will look at that shortly. Uh, so it is a potent broad spectrum antibiotic. Um, this mechanism of Axion is that it stops bacterial growth, so it binds to the bacterial ribosome blocking Pepto title transfers, thus inhibiting protein synthesis. So it's common to use in superficial I infections. Um, we can see it used very commonly, uh, for bacterial conjunctivitis, Uh, and this can be used in either an eye drop form or an eye ointment form. And there has, for a number of years, been a question over using chloramphenicol in in pediatrics. Um, there was a concern over the toxicity in chloramphenicol preparations that contained borax or boric acid buffers, and the m p h r A has recently this. This is only in the past. Um, I think 12 months has concluded, but chloramphenicol eye drops can be safely administered to Children age not too. And this is this is very good news, because very often, um, chloramphenicol can be passed between Children or picked up in swimming. Pools are picked up in playgroup, so Children are very, um very, uh, likely to get conjunctivitis. Bacterial conjunctivitis at some time in their their young life. So the MHR is mentioned. They've concluded the chloramphenicol eye drops can be safely administered the Children age not to to. And this advice supersedes regulatory advice, uh, from the European Medicines Agency, the M A and a safety alert published by the Royal College of Ophthalmologists. So hot off the press that we can use it. And, uh, I think it's it's quite good news, certainly so with respect to another use of chloramphenicol, which can be the IV or oral use very, very uncommon. In the 10 years that I've been practicing as a pharmacist, I have never once seen common fenical described by the or orally. And that's, um, what I was mentioning when I said that it's very commonly used for some indications and very uncommonly used in others. And I've mentioned it's very commonly used and superficial eye infections. It's very safe when used for bacterial conjunctivitis, but IV and oral use. I have personally never seen it in practice. Um, that's it. There are some things to consider if we wanted to prescribe it in IV roll uses that we need to avoid in pregnancy during due to a neonatal gray baby syndrome risk if used in the third trimester. And I preparations no information on topical use avoid and less essential due to risk above, um, and I such avoid and breastfeeding because it can be passed through the breast milk. Um, if a patient is used IV Rowley, Um, of course, there will be much higher volumes of it systemically if given in those, um, manners. So as such, we need to be mindful, um, and again, be cautious in pregnancy and with respect to the IV roll use, uh, it is associated with serious hematological side effects when given systemically, uh, and as mentioned, um, again, it's very uncommon. Um, And due to these serious sima theological side effects, when given systemically, it should therefore be reserved for the treatment of life threatening infections. So on one hand, it's very safe. We use it very often, uh, superficial. I infections. We use it very often both in primary care and secondary curve for for bacterial conjunctivitis. Um however, when you systemically, it is only reserved the treatment of life threatening infections due to the seriously mythological side effects. And as mentioned in my practice, it's something that I personally have never seen so just to close off the the lecture today, really, I wanted to look at something that is very important. I think it's something we need to be mindful of is we have touched on in some of the slides that we've already looked at, and that is antimicrobial stewardship. And what is it you might ask? Um well, antimicrobial stewardship refers to an organizational or healthcare system wide approach to promoting and monitoring judicious use of antimicrobials to preserve the future effectiveness. So again, it's it's something that we we all need to buy into as healthcare professionals. Um, it's not just organizational healthcare system wide approach. It also needs to be a personal approach to promoting the monitoring, judicious use of antimicrobials. We need to be very mindful that we're prescribing them for the right indication for the right duration, for the right effectiveness and and to ensure that patient's take them as prescribed to ensure that patient's complete the course of treatment. And this is something that, as a pharmacist, I always discuss uh, antibiotics when I am prescribing them or or giving them to a patient just to make them aware that they need to complete the course of treatment. Sometimes we see patient to get a week's treatment of, uh, let's say, a penicillin for a chest infection, and they might only take three or four days because they feel they feel better. But But what they don't know is that there's a reason why the course of treatment is seven days, and we need to ensure the patient's are very much on board with us when we're trying to promote antimicrobial stewardship. Uh, with respect to to antimicrobial sure chip in the UK Um, well, we address antimicrobial resistance to improving stewardship. It's a national medicines optimization priority. Um, it's lead in in England by the NHS England, and it is supported by public health England. And how can we How can we promote this or how can we promote antimicrobial stewardship? Or how can we help to, um, you know, to put up a defense buyer against antimicrobial resistance? Well, antimicrobial resistance can be managed by a combination, um, of, uh, interventions again, organizational healthcare system and personal approaches. And, uh, these interventions address Well, quite importantly, a political commitment to prioritize antimicrobial resistance. Uh, and this is where, um, certainly public health England and NHS, England would would come into because there needs to be a commitment by the government to prioritise antimicrobial resistance as a as a as a concern as a risk as a threat for the future. Um, it's also about monitoring antimicrobial use and resistance and microbes. Um so often we see in practice, uh, patient's that come in with repeated in elderly patient, for example, we may see elderly patient present. Certainly the demographic would be more women present with resistant urinary tract infections. It's very common in elderly patient's, um, you know, with antimicrobial stewardship, we would take a sample of the urine and we would actually in a lab ascertain what antibiotic is effective and what is resistant, and that would go into patients' notes so that we're we're again. It's a judicious use, so that's very much. One way to look at, um, the resistance of microbes also monitoring antimicrobial use. Um, well, very often see antibiotic stewardship rounds that go round wards and hospitals. Um, ascertaining is the correct antibiotics being used? Is it being used for the correct duration? Um, and that often times you have pharmacists, physicians, uh, and and often nurse specialist in it. And that's one way to monitor the antimicrobial use. Um, development of new drugs, treatments and diagnostics. Uh, it's new. Antibiotics have hasn't been many new antibiotics, uh, developed in the last number of years. So that's one of the the big things. It's a hot topic. Um, the diagnostics as mentioned diagnostics and using, uh, urine samples to ascertain what antibiotic would be appropriate for for repeat patient with urinary tract infection. So that's something to consider. Um, and, uh, and then this bit on individuals behavior. So as we mentioned, um, it's not just organizational healthcare system wide, um, it needs to be an individual behavior relating to infection prevention, to infection control, to antimicrobial use and to antimicrobial resistance. So it's something that, as physicians and medics of the future, we need to be very mindful of and very, uh, thoughtful of when we are prescribing antibiotics. And that brings us to that last section again, healthcare professionals prescribing decisions again. It's about utilizing the understanding that you develop and working with the team around you to ascertain what would be the most effective antibiotic. So we need to consider our healthcare professional prescribing decisions. So that's the end of the lecture. I have, um, developed just just a few short questions that would be You can answer in the chat, or I won't change the chat until I close the presentation. But there's a few few here. So what would you recommend for compile Oh, factor enteritis and an adult? So if you had two options, uh, with remission or tat recycling, this is just make you think from an antimicrobial perspective to ensure your prescribing the right medication for the right indication, um, erythromycin or tetra cycling? The answer, um, is a So is it remission or retro? My zing? Or the first line of choice for antibiotic treatment in compiler bacteria, OSIs and I ciprofloxacin and Tetris cycling or alternatives but not used for treatment of Children? And in the last decade, ciprofloxacin and tetracycline resistance rapidly increased in compiling factors. So essentially, it's something we need to think the sometimes there may be one option. Sometimes there may be more than one option when you're looking at an infection in patient's, and the most mindful thing we need to think of is what is the first line What is the second line? What are the resistance? Um, To the bacteria to the to the treatment. Um, also any co morbidities or contraindications? So oftentimes it's not as simple as just changing one. There are many things we need to consider. Uh, so what would you recommend for treatment of bacterial conjunctivitis? If you had the option of chloramphenicol or it's information, what would you recommend? And the answer is actually both. Both can be used for treatment of bacterial conjunctivitis. Um, I worked at Murrayfield Zay Hospital NHS Foundation Trust for a number of years. And chloramphenicol is the first line of treatment at Merval's, um, but again, more than one, uh, antibiotic can be used, and it's something that we need to consider. And I think this might be the last like, but what is true of gentamicin? It is bacteria static or individual dose titration in may be needed. Uh, the answer is, B uh, and the reason for that is the effectiveness of the many glycosides, including Janta, my zing, a concentration dependent. So as such, those is are titrated according to serum gentamicin concentration. So that is, uh, some of the reference sources that I have used, Please feel free to reach out, Um, some very good information, particularly on the National Institute for Health and Care, Excellence on Antimicrobial Stewardship and the use of antibiotics. Um, also in the US to have the National Library of Medicine, some fantastic papers on the use of biotics. And, of course, in your local country uh, you would have your formulary in the UK, we have the British national formulary and that that dictates, uh, exactly what drugs can be used for. What indications? Contraindications co morbidity side effects. All the weird, wonderful things with relation to prescribing of your antibiotics can be found in in in that book. Um, which has mentioned in the UK it is the B N f. So thank you very much for listening. And if you have any questions, I would be very happy to take them as much as I can help. Um, thank you very much for the lecture. There's no questions in the chat right now, but if anyone wants to write something or mute themselves to ask something now, um, do you take the chance? And also please do fill in the feedback form in the chat. Um, so if you could fill it in and confirm that you've done it, that would be great. Um, there is a question here. What are your Sorry, What are your reserved for using? Oh, gosh. Um, can you do you have access to the chat? Uh, just bear with me one minute. I just don't want to butcher the name, so yeah, I can see the question. Um, is there any further information on that? Um, you know what? Would you any indication again? I guess it depends on the indication. And it depends on the patient. Um, clarithromycin has a longer serum, half life. Um, a better tissue penetration in the rhythm, Eisen. So that actually allows for twice a day dosing for most common infections versus, um, four times a day. Dosing for rhythm is in. So oftentimes, if you have patients that are on many medications polypharmacy as we would call it, um, it might be easier for them to have a twice daily regimen rather than, um, four times daily. Um, also, if you're concerned about some of the side effects of the patient's, um, with the different macrolides, uh, again, you would consider that, um, So there are many, many, many reasons, Um, as to you know why you would consider one or the other. Okay. Well, thank you very much, everyone, Um, again, it's just really to to sort of give you an idea of some of the things that you must consider when you're prescribing antibiotics and certainly to lean on your pharmacist. And just to think about the different things from a pharmacy standpoint, um, to help. So thank you all very much for joining. I hope I was useful. A great privilege to be able to deliver it for you. Okay. Thank you very much. Thanks a lot for the Asan for your time. Like we appreciate it. My pleasure. And to everyone that's still here, if you could please fill in the feedback from and confirm that you filled it in and then I'll send over the certificate for everyone. I'll give that one a few minutes to do that before ending the meeting. Thank you. Thanks a lot. Everyone have a lovely day. Thank you. You too. Okay, I'll dial off now. Thanks very much. Everyone and, uh, all the best for your studies. I'm sure we'll speak soon.